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ANDHRA PRADESH POLLUTION CONTROL BOARD

2051

PARYAVARAN BHAVAN,
A-3, INDUSTRIAL ESTATE, SANATHNAGAR, HYDERABAD - 500 018.

Lr.No.44119/PCB/JA/TS/2007,

Date :__

To

Sir,
Sub:Ref:-

Issue of Water Consent forms for obtaining consent for operation Reg.
Your Lr.No_______
dt._____

*****
While acknowledging the receipt of the Demand Draft for Rs. 50/- through your letter cited, I enclose a set
of Consent forms in quadruplicate. You are informed that, as per Section 25 of the Water(Prevention and Control of
Pollution) Act, 1974 as amended, it is obligatory on the part of the person seeking Consent of the Board under
Section 25 of the Water(Prevention & Control of Pollution) Act, 1974 to ensure that his application for grant of
Consent for Operation should accompany with fees at the rates shown overleaf as per the A.P Gazette Notification
Part-1, dt:18.12.1997.
You are requested to submit the application in triplicate duly filled in along with Consent fee as per the
rates mentioned in the above Gazette Notification at concerned Regional Office of A.P. Pollution Control Board for
further necessary action. The criteria for fixing the Consent fee is the total investment of the industry. The total
investment should be reckoned as the entire investment including the cost of Land and Building on the industry, but
excluding the working capital. The depreciation on industry should not be taken in to consideration, in the case of
already established industries. In case the industry had expanded / proposed to go in for expansion, the cost of
expansion should also be taken into consideration.
The prescribed Consent fee is be paid by crossed Demand Draft drawn on any Scheduled bank in favour of
A.P. Pollution Control Bard payable at respective Head Quarters of concerned Regional Office.
You can apply for the maximum revised validity periods as per the following table:
SI.
Item
Maximum Validity Period
No.
1
CFO issuance for first time after obtaining CFE 1 year
irrespective of category of unit
2
Red Category units
2 years
3
Orange Category units
3 years
4
Green Category units
5 years
5
Units with ISO 14000 certificate irrespective of 1 year over and above the above
category (not for fresh cases)
period (SI.Nos. 2&3)
6
Cleaner Production Technology
3 years (Red Category only)
Note: To avail the maximum validity period, you are required to pay the Consent fee for the entire period along with
the application.
If the application is made for the renewal, you are requested to send a condition wise compliance report on
the conditions stipulated in the earlier Consent order issued by the Board.
Yours faithfully,
For Member Secretary.
Encl: Consent form
(in Quadruplicate)

A.P.Gazettee Notifiaction Part-1, date: 18.12.1997


Investment Rs. In
crores.

0 to 0.025
Above 0.025 to 0.25
Above 0.25 to 0.50
Above 0.50 to 1.00
Above 1.00 to 3.00
Above 3.00 to 5.00
Above 5.00 to 10.00
Above 10.00 to 25.00
Above 25.00 to 50.00
Above 50.00 to 100.00
Above 100.00 to
500.00
Above 500.00 to
1000.00
Above 1000.00 to
5000.00
Above 5000.00 to
10000.00
Above 10000.00 to
20000.00
Above 20000.00

Note:

Red Category
Industries generating
Non-Hazardous
Hazardous waste as per
Industries
HWM & H Rules, 1989

Orange Category
Industries generating
Non-Hazardous
Hazardous waste as per
Industries
HWM & H Rules, 1989

Rate of fee
on
investmen
t (%)
(Rounding
off to
nearest
Rs.100/-)
0.2000000
0.0400000
0.0250000
0.0250000
0.0250000
0.0300000
0.0300000
0.0150000
0.0100000
0.0750000
0.0030000

With
Minimum
amount of
Rs.

With
Minimu
m
amount
of Rs.

With
Minimum
amount of
Rs.

0.00
500.00
1000.00
1300.00
2500.00
7500.00
15000.00
30000.00
37500.00
50000.00
75000.00

Rate of
fee on
investmen
t (%)
(Roundin
g off to
nearest
Rs.100/-)
0.0150000
0.0300000
0.0187500
0.0187500
0.0187500
0.0225000
0.0225000
0.0112500
0.0007500
0.0062500
0.0022500

0.00
400.00
800.00
1000.00
1900.00
5700.00
11300.00
22500.00
28200.00
37500.00
62500.00

Rate of fee
on
investment
(%)
(Rounding
off to
nearest
Rs.100/-)
0.1000000
0.0200000
0.0125000
0.0125000
0.0150000
0.0150000
0.0150000
0.0075000
0.0050000
0.0037500
0.0015000

0.0025000

150000.00

0.0187580

112500.00

0.0070000

250000.00

0.0005250

0.0005000

350000.00

0.0005000
0.0050000

Green Category
Industries generating
Hazardous waste
as per HWM & H Rules,
1989
Rate of fee
With
on
Minimum
investment
amount
(%)
of Rs.
(Rounding
off to
nearest
Rs.100/-)
0.500000
0.00
0.0100000
100.00
0.0062500
300.00
0.0062500
400.00
0.0062500
700.00
0.0075000
1900.00
0.0075000
3800.00
0.0037500
7500.00
0.0025000
9400.00
0.0018750
12500.00
0.0007500
18800.00

With
Minimu
m
amount
of Rs.

0.00
300.00
500.00
700.00
1300.00
3800.00
7500.00
15000.00
18800.00
25000.00
37500.00

Rate of fee
on
investment
(%)
(Rounding
off to
nearest
Rs.100/-)
0.750000
0.0150000
0.0093500
0.0093500
0.0093500
0.0112500
0.0112500
0.0056000
0.0037500
0.0028000
0.0011000

0.0012500

75000.00

0.0009350

55000.00

0.0006250

37500.00

187500.00

0.0003500

125000.00

0.0002625

93500.00

0.0001750

62500.00

0.0003750

262500.00

0.0002500

175000.00

0.0001875

0.0001250

87500.00

500000.00

0.0003750

325000.00

0.0002500

250000.00

0.0001875

0.0001250

125000.00

1000000.0
0

0.0003750

750000.00

0.0002500

500000.00

0.0001875

131300.0
0
187500.0
0
375000.0
0

0.0012500

250000.00

0.00
200.00
400.00
500.00
1000.00
2800.00
5700.00
11300.00
14000.00
18800.00
28000.00

Consent for Operation / Renewal fee has to be paid annually, under Water Act,1974 and Air Act,1981
separately with the above rates, if the industry is having both Air & Water pollution. If any industry
is having water pollution only, they have to pay only one fee with the above rates. Similarly if any
industry is having only Air pollution they have to pay only one fee with above rates. The Hazardous
Waste generating industries have to pay Consent for Operation / renewal fee under Water Act and
Air Act separately and they need not pay any separate fees for the authorizations to be issued under
the Hazardous Waste (Management & Handling) Rules, 1989.

2051
ORIGINAL
PRICE Rs. 50/FORM XIII
To be submitted in Triplicate
For Member Secretary
APPLICATION FOR CONSENT FOR DISCHARGE / CONTINUATION OF
DISCHARGE UNDER SECTION 25 OF THE ACT.
(See rule 32)
APPLICATION FOR CONSENT FOR DISCHARGE/CONTINUATION OF DISCHARE
From..
.
.

Date:..

To
THE MEMBER SECRETARY
Andhra Pradesh Pollution Control Board
Paryavarana Bhavan,A-3,Industrial Estate,
Sanathnagar, Hyderabad- 500018.
Sir,
I/We apply for CONSENT under Section 25 of the Water ( Prevention and Control of Pollution Act, 1974
( No. 6 of 1974) or bring into any new or altered outlet for the discharge of Sewage / trade effluent to begin to make
new discharge of sewage / trade effluents or continue to make discharge of Sewage / trade effluent from land /
premises owned by (1).
for a period upto (2) ..
(a) Sewage /sullage Via drains / outfall sewers / treatment works.
(b) Trade effluent Via, drains / outfall sewers/treatment works.
(c) Solid wastes into (3):
(i) Stream ..
River OR
(ii) Onland for irrigation, bearing Survey No.
Adjoining/ at a
distance of ..
stream/ river OR
(iii) Lake, pond adjoining / at a distance of stream/River OR
(iv) Directly on land for open percolation into sub-terranean strata of survey No..
ADJOINING / AT A DISTANCE OF
OR
(v) Tidal waters / estuarine waters know as OR
(vi) Sea along/ off the seashore shown as
2. The Annexure , Appendices other particulars and plans in triplicate are attached herewith.
3. I/We further declare that the information furnished in the Annexure , Appendices and plans is
correct to the best of my/out knowledge.
4. I/ We hereby submit that in case of change either of the point or the quality of discharge or its
Quality, a fresh application for CONSENT shall be made and until such CONSENT is granted, no
change shall be made.
5. I/We hereby agree to submit to the State Board an application fro renewal of Consent one month in advance of
date of expiry of the consented period for outlet/discharge, if to be continued thereafter.
6. I/We undertake to furnish any other information within one month of its being called by the state Board.
7. An amount of Rs paid towards consent fee for .. years.
Yours faithfully
Signature
Name of applicant
Address of Applicant
ACCOMPANNIMENTS:
Note :- Strike out entries not relevant.

ANNEXURE TO FORM XIII


EXISTING / NEW/ ALTERED

OUTLET/ DISCHARGE
Note : Any applicant knowingly giving incorrect information or suppressing any information pertaining thereto shall
be liable to punished under the Act.
While filling this Annexure, the applicant not concerned with any of the items shall state Not Concerned against
the relevant one:
1.

Full Name of Applicant with Address :

2.

Full Name of land premises/ institute/


factory/ industry/ local body with address:

3.

Give revenue / city survey number of land/


premises for which the application is made
stating District/ Mandal and Village.

4.

State : month and year in which the


land/ premises/ institute/ factory/
industry was
actually put into commission or is
proposed
to be put into commission or the month
and
year from which the local body is
functioning.

5.

State the Civil/ Military/Defence/


Industrial
Estate etc., under whose administrative
jurisdiction the applicant's land/ premises
is
situated.

6.

(a) State whether the land/premises/


industry/ factory has been declared as
prohibited area.

(Tel No.)

(b) If yes, state the name of the


Authority
and furnish a certified copy to the order
under which the area has been
declared as prohibited area.

(Tel. No.)
District ..
Mandal
Town.
Village.
City Survey No. Mouza No.
Area in Hectares .
Revenue Survey No.
Area in Hectares..
..

Collectorate
Corporation
Municipality
Village Panchayat
Cantonment
Defence Department
Port Trust
State Government
Prohibited Area
Yes / No

7.
8.

9.

Is the industry/ factory for which


application
is made closed on Sunday/ Holiday?
State Working season per year for the
industry / factory.

Yes/ No
Full Year
From
From
From
..

(a) No. of workers attending the factory


Unit/Section

Shift No.1 Hrs

Shift No.2 Hrs

(b) No.of workers residing in the premises


10.

11.

To
To
To
Every year
Shift No.3 Hrs

General Shift Hrs

_________

For local Bodies only


(a) Present Population
(b) Population Covered under
regular sewerage facilities.
(c) Population covered by
conservancy latrines.
(d) Population having septic tank/
pit privy facilities.
(a) Give the list of raw materials, such as metals, alloys, chemicals, oil, fuels, etc., used per month in
Metric Tonnes :
Metal and Alloy
Chemicals

Name / Weight
Inorganic / Organic

Dyes I Pesticides

Name I Weight

Oils and Grease

Name I Weight

Fuel

(a) Wood

Name I Weight

(b) Coal

Name I Weight

(c) Oil

Name I Weight

(d) Gases

Name I Weight

(e) Others

Name I Weight

(b) Give the list of Names of products and by-products manufactures per month in (M.T)
SI. No.

Name of Products

( c ) Give the list of possible intermediate products:

Quantity in M.T. (Per


Month)

12.

13.

14.
15.

16.

16A
17.

18.

State daily quantity of water in litres


utilised.

A) State the hourly minimum and daily


maximum quantity of effluents arising
from land premises for which the
application is made.
(a) Domestic
(b) Industrial
(c) Agriculture
(d) Other use
(e) Total Quantity of effluent

USES
-----------------------------------------------------------(Domestic/Industrial/Agriculture/Other)
------------------------------------------------------(In Litres)
( Hourly Maximum / Daily Maximum)

(B) State how measurements of


RATE and QUANTITY are carried out.
State whether storm water drains are
kept separate from industrial/ domestic
effluents.
(a) Is domestic effluent allowed to get mixed
in industrial effluent ?

Yes / No
Yes / No

(b) (b) If yes, state ratio


(a) Describe if any treatment of industrial
or domestic effluent or one for the
combined effluent is made.
If yes, state the process of treatment in brief
(on a separate sheet)
(b) Is the quality of effluent emanating
either without or after treatment approved
by any authority?
(c) If approved, furnish the authority.
Is any effluent from any shop/ shops toxic? If
so volume of this effluent
Is there any provision for disposal of :
(a) Domestic effluent in public
underground Sewer.
(b) Industrial effluent in public
underground sewer.
(c) Give the name of the public authority
owning the sewer
Is there any provision for disposal of:
(a) Domestic effluent: on land for
irrigation
(b) Industrial effluent: on land for irrigation
(c) Domestic effluent in the
underground strata
(d) State the area of land used for (a)
above, in Hectares.
(e) State the area of land used for (b)
above, in hectares.

Domestic/Industrial
Yes / No

Yes / No
(Two certified copies to be send)
Yes / No
Already made

Proposed to be made

Yes/No

Yes/No

Yes/No

Yes/No

Already made

Proposed to be made

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

19.

Given quantitative disposal of effluent in litres provided for the places mentioned below:
Domesti
c

Industrial

Mixed

(i)Stream/ River ........................................................


(ii)On land for irrigation ..........................................
(iii)On land for percolation ......................................
(iv)Lake/Pond .........................................................
(v)Tidal Waters ..........................................................
(vi)Estuarine Waters ....
(vii)Open Sea ..............................................................
20.

Is there any provision for equalizing or holding lagoons for tanks to store the effluents during
unfavourable stream of tidal conditions?
Type of Effluent
i)Domestic effluent
ii)Industrial effluent
iii)Combined effluent

Already made

21.

Is sufficient land available / can be made available in


caste pumping of the effluent on land has to be
considered ?

22.

(a) Give details of composition of Domestic/ Industrial/ Combined


effluents in respect of the fol!owing:
Effluent before treatment
At
At
At
Max
Vain
Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)
OH
Colour - Units
Temperature C
Suspended solids :
(a)Total mg/I
(b)Fixed mg/I
(c)Volatile mg/I
(v) Dissolved solids :
(a)Total mg/I
(b)Fixed mg/I
(c)Volatile mg/I
(vi) Total volatile Matter mg/I
(vii) Ammonical Nitrogen (mg/I) N
(viii) Nitrates (mg/I) N
(i)
(ii)
(iii)
(iv)

Proposed to be made

Yes / No

Effluent after treatment


At
At
At
Max
Min Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

Effluent before treatment


At
At
At
Max
Vain
Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

Effluent after treatment


At
At
At
Max
Min Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

(ix) Dissolved Oxygen mg/I


(x)

BOD5 at 20C mg/I

(xi) C.O.D. mg/I


(xii) Oil & grease mg/l
(xiii) Chlorides (as CI) mg/I
(xiv) Phosphates (as P) mg/I
(xv) Phenolic compounds mg/l (as Phenol)
(xvi) Cyanides (as CN) mg/I
(xvii) Sulphides (as S) mg/I
(xviii) Sulphates (as SO4) mg/I
(xix) Insecticides mg/I
(xx) Total residual chlorine (as Cl2) mg/I
(xxi) Fluoride (as F) mg/I
(xxii) Boron (as B) mg/I
(xxiii) Arsenic (as As) mg/I
(xxiv) Barium (as Ba) mg/I
(xxv) Percent Sodium
(xxvi) Cadmium (as Cd) mg/l
(xxvii) Copper (as Cu) mg/I
(xxviii) Lead (as Pb) mg/I
(xxix-) Chromium
(a) as Cr (mg/I)
(b) Hexa-Valency (as Cr+6) mg/I
(xxx) Mercury (as Hg) mg/i
(xxxi) Nickel (as Ni) mg/I
(xxxii) Selenium (as Se) mg/I
(xxxiii) Silver((as Ag).mg/I
,(xxxiv) Zinc (as Zn) mg/1
(xxxv) Any other metals mg/I
(xxxvi) Calcium Chloroform Extracts
(xxxvii) Pesticides (mg/1)
(xxxviii) Coliform Organisms
MPN per 100 ml. (monthly average)
(xxxix) Bioassay for Toxic constituents. TL 50 (96) hours
Note:.(1)

Furnish a copy of the analysis report of representative samples carried out by a competent

(2)

laboratory
Methods of determination as approved by the Board will be followed for determination of
above mentioned parameters.

22.

23.

(b)

Yes / No

Is the effluent toxic ?


(c)State if the industrial effluent is having
i. Unpleasant smell
ii. Irritating and / or harmful effect
iii. Corrosive
iv. Colour

Yes / No
Yes / No
Yes / No
Yes / No

(d) Is there any sudden change of temperature


exceeding 10C at any time ?
Are
facilities available with the applicant for carrying out the following tests of the waste water ?
(a)
i.
ii.
iii.
iv.

Existing
Yes/No
Yes/No
Yes/No
Yes/No

Physical
Chemical
Bacteriological
Toxicological

Proposed
Yes/No
Yes/No
Yes/No
Yes/No

(b) if yes, details of equipment


24.

Does the Land/ Premises etc., (for which application is made) have open
Highly Polluting Matter
Toxic

Organic

Inorganic

Microbiological

(a)Cooling Tanks
(b)Mixing Tanks
(c)Mixing ponds

Which contain

(d)Re-circulation wells

25.

State details of solid wastes


Dis.

Qty.

Method of collection

Method of disposal

Seasonal Waste
Spillage
Rejected materials
Signature
__________________________________
Name & address of the applicant on behalf
of________
Name and address of the firm
__________________________________________
_

ACCOMPANIMENTS
Flow Sheet of effluents

EXPLANATORY NOTES FOR FILLING IN FORM X111 AND THE ANNEXURE


The Notes are given only for those items for which explanation is considered desirable: other
items are self explanatory.
Form XIII
Here mentions the name of the owner of the land/ premises if other than the applicant industry of
factory if the land/ premises belongs-to-the factory / industry say SELF.
2. Here mention the date upto which the Consent is sought for.
3. Here mention the local name of the river/ stream tidal water/sea as may be applicable.
1

ANNEXURE TO FORM XIII


"Outlet"

Means the arrangement for discharge of the effluent for which the Consent is sought for

"Discharge"

Means the effluent going out of the outlet.

"Existing"

Means that which is in operation at the time of applying for Consent.

"New"

Means that which will be brought into operation in future.

"Altered"

Means that which has been modified due to charge in quality and/or quality or discharge.

Item 1

-Here give the name of the person who is authorized by the instruction/
Industry/Factory/Local body etc., to transact their legal business.

Item 2

-Here give the registered name of the Institution/ Factory/Industry etc., under which the
business is carried out

Item 5

Here state the concerned institution as Bureau of Public Enterprises, under whose
administrative control the Factory/ Industry etc., is set up.

Item 6

Here state the concerned institution as Bureau of Public Enterprises, under whose
administrative control the Factory/ Industry etc., is set up. Applicable to only those areas
which are prohibited areas such as the Ordinance Factories, Mint, etc.,

Item 13

(B) - State the method of measurement of hourly/ daily maximum quantity of effluent
i.e., by flow meters, Venturimeters, V notch sump measurements, or approximately
estimated etc.,

Item 16(a)

If the effluent is treated, give separately the method of treatment and flow diagram of the
treatment process.

Item 16(b)

Here mention "Yes" if any other authority such as the local body, or Government
Department has already approved the discharge of effluent either with or without
treatment, at the time of establishment of the Factory/ Industry.

Item 19

Here give the quantity of effluent of different types such as domestic, industrial or mixed
Etc., Proposed to be or is let into the stream/river, land, sea etc., as may be applicable.

Item 22

Analysis to be furnished shall cover as many Parameters as or expected to be found, in


the effluent if some of the parameters are not excepted to be found, say not applicable. If
some other Parameters than those listed under the items are expected the same may be
mentioned at the end. The analysis shall be separately furnished for domestic/ industrial and
combined effluents.

Item 22(b)

Here toxicity means that which is established by bio-assay studies on fish, as per
procedure given in the Standard Methods.

Item 24

This item is meant to cover such highly polluting substances which do not ordinarily find
way in effluents, but are required to be handled in the premises, and which may, by
accident, join the effluent in large quantities.
*****

2051
DUPLICATE
FORM XIII
To be submitted in Triplicate

PRICE Rs. 50/For Member Secretary

APPLICATION FOR CONSENT FOR DISCHARGE / CONTINUATION OF


DISCHARGE UNDER SECTION 25 OF THE ACT.
(See rule 32)
APPLICATION FOR CONSENT FOR DISCHARGE/CONTINUATION OF DISCHARE
From..
.
.

Date:..

To
THE MEMBER SECRETARY
Andhra Pradesh Pollution Control Board
Paryavarana Bhavan,A-3,Industrial Estate,
Sanathnagar, Hyderabad- 500018.
Sir,
I/We apply for CONSENT under Section 25 of the Water ( Prevention and Control of Pollution Act, 1974
( No. 6 of 1974) or bring into any new or altered outlet for the discharge of Sewage / trade effluent to begin to make
new discharge of sewage / trade effluents or continue to make discharge of Sewage / trade effluent from land /
premises owned by (1).
for a period upto (2) ..
(d) Sewage /sullage Via drains / outfall sewers / treatment works.
(e) Trade effluent Via, drains / outfall sewers/treatment works.
(f) Solid wastes into (3):
(i) Stream ..
River OR
(ii) Onland for irrigation, bearing Survey No.
Adjoining/ at a
distance of ..
stream/ river OR
(iii) Lake, pond adjoining / at a distance of stream/River OR
(iv) Directly on land for open percolation into sub-terranean strata of survey No..
ADJOINING / AT A DISTANCE OF
OR
(v) Tidal waters / estuarine waters know as OR
(vi) Sea along/ off the seashore shown as
2. The Annexure , Appendices other particulars and plans in triplicate are attached herewith.
3. I/We further declare that the information furnished in the Annexure , Appendices and plans is
correct to the best of my/out knowledge.
4. I/ We hereby submit that in case of change either of the point or the quality of discharge or its
Quality, a fresh application for CONSENT shall be made and until such CONSENT is granted, no
change shall be made.
5. I/We hereby agree to submit to the State Board an application fro renewal of Consent one month in advance of
date of expiry of the consented period for outlet/discharge, if to be continued thereafter.
6. I/We undertake to furnish any other information within one month of its being called by the state Board.
7. An amount of Rs paid towards consent fee for .. years.
Yours faithfully
Signature
Name of applicant
Address of Applicant
ACCOMPANNIMENTS:
Note :- Strike out entries not relevant.

ANNEXURE TO FORM XIII


EXISTING / NEW/ ALTERED
OUTLET/ DISCHARGE
Note : Any applicant knowingly giving incorrect information or suppressing any information pertaining thereto shall
be liable to punished under the Act.
While filling this Annexure, the applicant not concerned with any of the items shall state Not Concerned against
the relevant one:
1.

Full Name of Applicant with Address :

2.

Full Name of land premises/ institute/


factory/ industry/ local body with address:

3.

Give revenue / city survey number of land/


premises for which the application is made
stating District/ Mandal and Village.

4.

State : month and year in which the


land/ premises/ institute/ factory/
industry was
actually put into commission or is
proposed
to be put into commission or the month
and
year from which the local body is
functioning.

5.

State the Civil/ Military/Defence/


Industrial
Estate etc., under whose administrative
jurisdiction the applicant's land/ premises
is
situated.

6.

(a) State whether the land/premises/


industry/ factory has been declared as
prohibited area.

(Tel No.)

(b) If yes, state the name of the


Authority
and furnish a certified copy to the order
under which the area has been
declared as prohibited area.

(Tel. No.)
District ..
Mandal
Town.
Village.
City Survey No. Mouze No.
Area in Hectares .
Revenue Survey No.
Area in Hectares..
..

Collectorate
Corporation
Municipality
Village Panchayat
Cantonment
Defence Department
Port Trust
State Government
Prohibited Area
Yes / No

7.
8.

9.

Is the industry/ factory for which


application
is made closed on Sunday/ Holiday?
State Working season per year for the
industry / factory.

Yes/ No
Full Year
From
From
From
..

(a) No. of workers attending the factory


Unit/Section

Shift No.1 Hrs

Shift No.2 Hrs

(b) No.of workers residing in the premises


10.

11.

To
To
To
every year
Shift No.3 Hrs

General Shift Hrs

_________

For local Bodies only


(e) Present Population
(f) Population Covered under
regular sewerage facilities.
(g) Population covered by
conservancy latrines.
(h) Population having septic tank/
pit privy facilities.
(a) Give the list of raw materials, such as metals, alloys, chemicals, oil, fuels, etc., used per month in
Metric Tonnes :
Metal and Alloy
Chemicals

Name / Weight
Inorganic / Organic

Dyes I Pesticides

Name I Weight

Oils and Grease

Name I Weight

Fuel

(a) Wood

Name I Weight

(b) Coal

Name I Weight

(c) Oil

Name I Weight

(d) Gases

Name I Weight

(e) Others

Name I Weight

(b) Give the list of Names of products and by-products manufactures per month in (M.T)
SI. No.

Name of Products

( c ) Give the list of possible intermediate products:

Quantity in M.T. (Per


Month)

12.

13.

14.
15.

16.

16A
17.

18.

State daily quantity of water in litres


utilised.

A) State the hourly minimum and daily


maximum quantity of effluents arising
from land premises for which the
application is made.
(f) Domestic
(g) Industrial
(h) Agriculture
(i) Other use
(j) Total Quantity of effluent

USES
-----------------------------------------------------------(Domestic/Industrial/Agriculture/Other)
------------------------------------------------------(In Litres)
( Hourly Maximum / Daily Maximum)

(B) State how measurements of


RATE and QUANTITY are carried out.
State whether storm water drains are
kept separate from industrial/ domestic
effluents.
(a) Is domestic effluent allowed to get mixed
in industrial effluent?

Yes / No
Yes / No

(b) (b) If yes, state ratio


(a) Describe if any treatment of industrial
or domestic effluent or one for the
combined effluent is made.
If yes, state the process of treatment in brief
(on a separate sheet)
(b) Is the quality of effluent emanating
either without or after treatment approved
by any authority?
(c) If approved, furnish the authority.
Is any effluent from any shop/ shops toxic? If
so volume of this effluent
Is there any provision for disposal of :
(d) Domestic effluent in public
underground Sewer.
(e) Industrial effluent in public
underground sewer.
(f) Give the name of the public authority
owning the sewer
Is there any provision for disposal of:
(f) Domestic effluent: on land for
irrigation
(g) Industrial effluent: on land for irrigation
(h) Domestic effluent in the
underground strata
(i) State the area of land used for (a)
above, in Hectares.
(j) State the area of land used for (b)
above, in hectares.

Domestic/Industrial
Yes / No

Yes / No
(Two certified copies to be send)
Yes / No
Already made

Proposed to be made

Yes/No

Yes/No

Yes/No

Yes/No

Already made

Proposed to be made

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

19.

Given quantitative disposal of effluent in litres provided for the places mentioned below:
Domesti
c

Industrial

Mixed

(i)Stream/ River ........................................................


(ii)On land for irrigation ..........................................
(iii)On land for percolation ......................................
(iv)Lake/Pond .........................................................
(v)Tidal Waters ..........................................................
(vi)Estuarine Waters ....
(vii)Open Sea ..............................................................
20.

Is there any provision for equalizing or holding lagoons for tanks to store the effluents during
unfavourable stream of tidal conditions?
Type of Effluent
i)Domestic effluent
ii)Industrial effluent
iii)Combined effluent

Already made

21.

Is sufficient land available / can be made available in


caste pumping of the effluent on land has to be
considered ?

22.

(a) Give details of composition of Domestic/ Industrial/ Combined


effluents in respect of the fol!owing:
Effluent before treatment
At
At
At
Max
Vain
Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)
OH
Colour - Units
Temperature C
Suspended solids :
(a)Total mg/I
(b)Fixed mg/I
(c)Volatile mg/I
(v) Dissolved solids :
(a)Total mg/I
(b)Fixed mg/I
(c)Volatile mg/I
(vi) Total volatile Matter mg/I
(vii) Ammonical Nitrogen (mg/I) N
(viii) Nitrates (mg/I) N
(i)
(ii)
(iii)
(iv)

Proposed to be made

Yes / No

Effluent after treatment


At
At
At
Max
Min Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

Effluent before treatment


At
At
At
Max
Vain
Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

Effluent after treatment


At
At
At
Max
Min Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

(ix) Dissolved Oxygen mg/I


(x)

BOD5 at 20C mg/I

(xi) C.O.D. mg/I


(xii) Oil & grease mg/l
(xiii) Chlorides (as CI) mg/I
(xiv) Phosphates (as P) mg/I
(xv) Phenolic compounds mg/l (as Phenol)
(xvi) Cyanides (as CN) mg/I
(xvii) Sulphides (as S) mg/I
(xviii) Sulphates (as SO4) mg/I
(xix) Insecticides mg/I
(xx) Total residual chlorine (as Cl2) mg/I
(xxi) Fluoride (as F) mg/I
(xxii) Boron (as B) mg/I
(xxiii) Arsenic (as As) mg/I
(xxiv) Barium (as Ba) mg/I
(xxv) Percent Sodium
(xxvi) Cadmium (as Cd) mg/l
(xxvii) Copper (as Cu) mg/I
(xxviii) Lead (as Pb) mg/I
(xxix-) Chromium
(a) as Cr (mg/I)
(b) Hexa-Valency (as Cr+6) mg/I
(xxx) Mercury (as Hg) mg/i
(xxxi) Nickel (as Ni) mg/I
(xxxii) Selenium (as Se) mg/I
(xxxiii) Silver((as Ag).mg/I
,(xxxiv) Zinc (as Zn) mg/1
(xxxv) Any other metals mg/I
(xxxvi) Calcium Chloroform Extracts
(xxxvii) Pesticides (mg/1)
(xxxviii) Coliform Organisms
MPN per 100 ml. (monthly average)
(xxxix) Bioassay for Toxic constituents. TL 50 (96) hours
Note:.(1)

Furnish a copy of the analysis report of representative samples carried out by a competent

(3)

laboratory
Methods of determination as approved by the Board will be followed for determination of
above mentioned parameters.

22.

23.

(c)

Yes / No

Is the effluent toxic ?


(c)State if the industrial effluent is having
v. Unpleasant smell
vi. Irritating and / or harmful effect
vii. Corrosive
viii. Colour

Yes / No
Yes / No
Yes / No
Yes / No

(d) Is there any sudden change of temperature


exceeding 10C at any time ?
Are
facilities available with the applicant for carrying out the following tests of the waste water?
(a)
v.
vi.
vii.
viii.

Existing
Yes/No
Yes/No
Yes/No
Yes/No

Physical
Chemical
Bacteriological
Toxicological

Proposed
Yes/No
Yes/No
Yes/No
Yes/No

(b) if yes, details of equipment


24.

Does the Land/ Premises etc., (for which application is made) have open
Highly Polluting Matter
Toxic

Organic

Inorganic

Microbiological

(a)Cooling Tanks
(b)Mixing Tanks
(c)Mixing ponds

Which contain

(d)Re-circulation wells

25.

State details of solid wastes


Dis.

Qty.

Method of collection

Method of disposal

Seasonal Waste
Spillage
Rejected materials
Signature
__________________________________
Name & address of the applicant on behalf
of________
Name and address of the firm
__________________________________________
_

ACCOMPANIMENTS
Flow Sheet of effluents

EXPLANATORY NOTES FOR FILLING IN FORM X111 AND THE ANNEXURE


The Notes are given only for those items for which explanation is considered desirable : other
items are self explanatory.
Form XIII
Here mentions the name of the owner of the land/ premises if other than the applicant industry of
factory if the land/ premises belongs-to-the factory / industry say SELF.
2. Here mention the date upto which the Consent is sought for.
3. Here mention the local name of the river/ stream tidal water/sea as may be applicable.
1

s"Outlet"

ANNEXURE TO FORM XIII


Means the arrangement for discharge of the effluent for which the Consent is sought for

"Discharge"

Means the effluent going out of the outlet.

"Existing"

Means that which is in operation at the time of applying for Consent.

"New"

Means that which will be brought into operation in future.

"Altered"

Means that which has been modified due to charge in quality and/or quality or discharge.

Item 1

-Here give the name of the person who is authorized by the instruction/
Industry/Factory/Local body etc., to transact their legal business.

Item 2

-Here give the registered name of the Institution/ Factory/Industry etc., under which the
business is carried out

Item 5

Here state the concerned institution as Bureau of Public Enterprises, under whose
administrative control the Factory/ Industry etc., is set up.

Item 6

Here state the concerned institution as Bureau of Public Enterprises, under whose
administrative control the Factory/ Industry etc., is set up. Applicable to only those areas
which are prohibited areas such as the Ordinance Factories, Mint, etc.,

Item 13

(B) - State the method of measurement of hourly/ daily maximum quantity of effluent
i.e., by flow
meters, Venturimeters, V notch sump measurements, or approximately estimated etc.,

Item 16(a)

If the effluent is treated, give separately the method of treatment and flow diagram of the
treatment process.

Item 16(b)

Here mention "Yes" if any other authority such as the local body, or Government
Department has already approved the discharge of effluent either with or without
treatment, at the time of establishment of the Factory/ Industry.

Item 19

Here give the quantity of effluent of different types such as domestic, industrial or mixed
Etc., Proposed to be or is let into the stream/river, land, sea etc., as may be applicable.

Item 22

Analysis to be furnished shall cover as many Parameters as or expected to be found, in


the effluent if some of the parameters are not excepted to be found, say not applicable. If
some other Parameters than those listed under the items are expected the same may be
mentioned at the end. The analysis shall be separately furnished for domestic/ industrial and
combined effluents.

Item 22(b)

Here toxicity means that which is established by bio-assay studies on fish, as per
procedure given in the Standard Methods.

Item 24

This item is meant to cover such highly polluting substances which do not ordinarily find
way in effluents, but are required to be handled in the premises, and which may, by
accident, join the effluent in large quantities.

*****

2051
TRIPLICATE
PRICE Rs. 50/FORM XIII
To be submitted in Triplicate
For Member Secretary
APPLICATION FOR CONSENT FOR DISCHARGE / CONTINUATION OF
DISCHARGE UNDER SECTION 25 OF THE ACT.
(See rule 32)
APPLICATION FOR CONSENT FOR DISCHARGE/CONTINUATION OF DISCHARE
From..
.
.

Date:..

To
THE MEMBER SECRETARY
Andhra Pradesh Pollution Control Board
Paryavarana Bhavan,A-3,Industrial Estate,
Sanathnagar, Hyderabad- 500018.
Sir,
I/We apply for CONSENT under Section 25 of the Water ( Prevention and Control of Pollution Act, 1974
( No. 6 of 1974) or bring into any new or altered outlet for the discharge of Sewage / trade effluent to begin to make
new discharge of sewage / trade effluents or continue to make discharge of Sewage / trade effluent from land /
premises owned by (1).
for a period upto (2) ..
(g) Sewage /sullage Via drains / outfall sewers / treatment works.
(h) Trade effluent Via, drains / outfall sewers/treatment works.
(i) Solid wastes into (3):
(i) Stream ..
River OR
(ii) Onland for irrigation, bearing Survey No.
Adjoining/ at a
distance of ..
stream/ river OR
(iii) Lake, pond adjoining / at a distance of stream/River OR
(iv) Directly on land for open percolation into sub-terranean strata of survey No..
ADJOINING / AT A DISTANCE OF
OR
(v) Tidal waters / estuarine waters know as OR
(vi) Sea along/ off the seashore shown as
2. The Annexure , Appendices other particulars and plans in triplicate are attached herewith.
3. I/We further declare that the information furnished in the Annexure , Appendices and plans is
correct to the best of my/out knowledge.
4. I/ We hereby submit that in case of change either of the point or the quality of discharge or its
Quality, a fresh application for CONSENT shall be made and until such CONSENT is granted, no
change shall be made.
5. I/We hereby agree to submit to the State Board an application fro renewal of Consent one month in advance of
date of expiry of the consented period for outlet/discharge, if to be continued thereafter.
6. I/We undertake to furnish any other information within one month of its being called by the state Board.
7. An amount of Rs paid towards consent fee for .. years.
Yours faithfully
Signature
Name of applicant
Address of Applicant
ACCOMPANNIMENTS:
Note :- Strike out entries not relevant.

ANNEXURE TO FORM XIII


EXISTING / NEW/ ALTERED
OUTLET/ DISCHARGE
Note : Any applicant knowingly giving incorrect information or suppressing any information pertaining thereto shall
be liable to punished under the Act.
While filling this Annexure, the applicant not concerned with any of the items shall state Not Concerned against
the relevant one:
1.

Full Name of Applicant with Address :

2.

Full Name of land premises/ institute/


factory/ industry/ local body with address:

3.

Give revenue / city survey number of land/


premises for which the application is made
stating District/ Mandal and Village.

4.

State : month and year in which the


land/ premises/ institute/ factory/
industry was
actually put into commission or is
proposed
to be put into commission or the month
and
year from which the local body is
functioning.

5.

State the Civil/ Military/Defence/


Industrial
Estate etc., under whose administrative
jurisdiction the applicant's land/ premises
is
situated.

6.

(a) State whether the land/premises/


industry/ factory has been declared as
prohibited area.

(Tel No.)

(b) If yes, state the name of the


Authority
and furnish a certified copy to the order
under which the area has been
declared as prohibited area.

(Tel. No.)
District ..
Mandal
Town.
Village.
City Survey No. Mouze No.
Area in Hectares .
Revenue Survey No.
Area in Hectares..
..

Collectorate
Corporation
Municipality
Village Panchayat
Cantonment
Defence Department
Port Trust
State Government
Prohibited Area
Yes / No

7.
8.

9.

Is the industry/ factory for which


application
is made closed on Sunday/ Holiday?
State Working season per year for the
industry / factory.

Yes/ No
Full Year
From
From
From
..

(a) No. of workers attending the factory


Unit/Section

Shift No.1 Hrs

Shift No.2 Hrs

(b) No.of workers residing in the premises


10.

11.

To
To
To
every year
Shift No.3 Hrs

General Shift Hrs

_________

For local Bodies only


(i) Present Population
(j) Population Covered under
regular sewerage facilities.
(k) Population covered by
conservancy latrines.
(l) Population having septic tank/
pit privy facilities.
(a) Give the list of raw materials, such as metals, alloys, chemicals, oil, fuels, etc., used per month in
Metric Tonnes :
Metal and Alloy
Chemicals

Name / Weight
Inorganic / Organic

Dyes I Pesticides

Name I Weight

Oils and Grease

Name I Weight

Fuel

(a) Wood

Name I Weight

(b) Coal

Name I Weight

(c) Oil

Name I Weight

(d) Gases

Name I Weight

(e) Others

Name I Weight

(b) Give the list of Names of products and by-products manufactures per month in (M.T)
SI. No.

Name of Products

( c ) Give the list of possible intermediate products:

Quantity in M.T. (Per


Month)

12.

13.

14.
15.

16.

16A
17.

18.

State daily quantity of water in litres


utilised.

A) State the hourly minimum and daily


maximum quantity of effluents arising
from land premises for which the
application is made.
(k) Domestic
(l) Industrial
(m) Agriculture
(n) Other use
(o) Total Quantity of effluent

USES
-----------------------------------------------------------(Domestic/Industrial/Agriculture/Other)
------------------------------------------------------(In Litres)
( Hourly Maximum / Daily Maximum)

(B) State how measurements of


RATE and QUANTITY are carried out.
State whether storm water drains are
kept separate from industrial/ domestic
effluents.
(a) Is domestic effluent allowed to get mixed
in industrial effluent ?

Yes / No
Yes / No

(b) (b) If yes, state ratio


(a) Describe if any treatment of industrial
or domestic effluent or one for the
combined effluent is made.
If yes, state the process of treatment in brief
(on a separate sheet)
(b) Is the quality of effluent emanating
either without or after treatment approved
by any authority?
(c) If approved, furnish the authority.
Is any effluent from any shop/ shops toxic? If
so volume of this effluent
Is there any provision for disposal of :
(g) Domestic effluent in public
underground Sewer.
(h) Industrial effluent in public
underground sewer.
(i) Give the name of the public authority
owning the sewer
Is there any provision for disposal of:
(k) Domestic effluent: on land for
irrigation
(l) Industrial effluent: on land for irrigation
(m) Domestic effluent in the
underground strata
(n) State the area of land used for (a)
above, in Hectares.
(o) State the area of land used for (b)
above, in hectares.

Domestic/Industrial
Yes / No

Yes / No
(Two certified copies to be send)
Yes / No
Already made

Proposed to be made

Yes/No

Yes/No

Yes/No

Yes/No

Already made

Proposed to be made

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

19.

Given quantitative disposal of effluent in litres provided for the places mentioned below:
Domesti
c

Industrial

Mixed

(i)Stream/ River ........................................................


(ii)On land for irrigation ..........................................
(iii)On land for percolation ......................................
(iv)Lake/Pond .........................................................
(v)Tidal Waters ..........................................................
(vi)Estuarine Waters ....
(vii)Open Sea ..............................................................
20.

Is there any provision for equalizing or holding lagoons for tanks to store the effluents during
unfavourable stream of tidal conditions?
Type of Effluent
i)Domestic effluent
ii)Industrial effluent
iii)Combined effluent

Already made

21.

Is sufficient land available / can be made available in


caste pumping of the effluent on land has to be
considered ?

22.

(a) Give details of composition of Domestic/ Industrial/ Combined


effluents in respect of the fol!owing:
Effluent before treatment
At
At
At
Max
Vain
Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)
OH
Colour - Units
Temperature C
Suspended solids :
(a)Total mg/I
(b)Fixed mg/I
(c)Volatile mg/I
(v) Dissolved solids :
(a)Total mg/I
(b)Fixed mg/I
(c)Volatile mg/I
(vi) Total volatile Matter mg/I
(vii) Ammonical Nitrogen (mg/I) N
(viii) Nitrates (mg/I) N
(i)
(ii)
(iii)
(iv)

Proposed to be made

Yes / No

Effluent after treatment


At
At
At
Max
Min Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

Effluent before treatment


At
At
At
Max
Vain
Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

Effluent after treatment


At
At
At
Max
Min Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

(ix) Dissolved Oxygen mg/I


(x)

BOD5 at 20C mg/I

(xi) C.O.D. mg/I


(xii) Oil & grease mg/l
(xiii) Chlorides (as CI) mg/I
(xiv) Phosphates (as P) mg/I
(xv) Phenolic compounds mg/l (as Phenol)
(xvi) Cyanides (as CN) mg/I
(xvii) Sulphides (as S) mg/I
(xviii) Sulphates (as SO4) mg/I
(xix) Insecticides mg/I
(xx) Total residual chlorine (as Cl2) mg/I
(xxi) Fluoride (as F) mg/I
(xxii) Boron (as B) mg/I
(xxiii) Arsenic (as As) mg/I
(xxiv) Barium (as Ba) mg/I
(xxv) Percent Sodium
(xxvi) Cadmium (as Cd) mg/l
(xxvii) Copper (as Cu) mg/I
(xxviii) Lead (as Pb) mg/I
(xxix-) Chromium
(a) as Cr (mg/I)
(b) Hexa-Valency (as Cr+6) mg/I
(xxx) Mercury (as Hg) mg/i
(xxxi) Nickel (as Ni) mg/I
(xxxii) Selenium (as Se) mg/I
(xxxiii) Silver((as Ag).mg/I
,(xxxiv) Zinc (as Zn) mg/1
(xxxv) Any other metals mg/I
(xxxvi) Calcium Chloroform Extracts
(xxxvii) Pesticides (mg/1)
(xxxviii) Coliform Organisms
MPN per 100 ml. (monthly average)
(xxxix) Bioassay for Toxic constituents. TL 50 (96) hours
Note:.(1)

Furnish a copy of the analysis report of representative samples carried out by a competent

(4)

laboratory
Methods of determination as approved by the Board will be followed for determination of
above mentioned parameters.

22.

23.

(d)

Yes / No

Is the effluent toxic ?


(c)State if the industrial effluent is having
ix. Unpleasant smell
x. Irritating and / or harmful effect
xi. Corrosive
xii. Colour

Yes / No
Yes / No
Yes / No
Yes / No

(d) Is there any sudden change of temperature


exceeding 10C at any time ?
Are
facilities available with the applicant for carrying out the following tests of the waste water ?
(a)
ix.
x.
xi.
xii.

Existing
Yes/No
Yes/No
Yes/No
Yes/No

Physical
Chemical
Bacteriological
Toxicological

Proposed
Yes/No
Yes/No
Yes/No
Yes/No

(b) if yes, details of equipment


24.

Does the Land/ Premises etc., (for which application is made) have open
Highly Polluting Matter
Toxic

Organic

Inorganic

Microbiological

(a)Cooling Tanks
(b)Mixing Tanks
(c)Mixing ponds

Which contain

(d)Re-circulation wells

25.

State details of solid wastes


Dis.

Qty.

Method of collection

Method of disposal

Seasonal Waste
Spillage
Rejected materials
Signature
__________________________________
Name & address of the applicant on behalf
of________
Name and address of the firm
__________________________________________
_

ACCOMPANIMENTS
Flow Sheet of effluents

EXPLANATORY NOTES FOR FILLING IN FORM X111 AND THE ANNEXURE


The Notes are given only for those items for which explanation is considered desirable: other
items are self explanatory.
Form XIII
Here mentions the name of the owner of the land/ premises if other than the applicant industry of
factory if the land/ premises belongs-to-the factory / industry say SELF.
2. Here mention the date upto which the Consent is sought for.
3. Here mention the local name of the river/ stream tidal water/sea as may be applicable.
1

"Outlet"

ANNEXURE TO FORM XIII


Means the arrangement for discharge of the effluent for which the Consent is sought for

"Discharge"

Means the effluent going out of the outlet.

"Existing"

Means that which is in operation at the time of applying for Consent.

"New"

Means that which will be brought into operation in future.

"Altered"

Means that which has been modified due to charge in quality and/or quality or discharge.

Item 1

-Here give the name of the person who is authorized by the instruction/
Industry/Factory/Local body etc., to transact their legal business.

Item 2

-Here give the registered name of the Institution/ Factory/Industry etc., under which the
business is carried out

Item 5

Here state the concerned institution as Bureau of Public Enterprises, under whose
administrative control the Factory/ Industry etc., is set up.

Item 6

Here state the concerned institution as Bureau of Public Enterprises, under whose
administrative control the Factory/ Industry etc., is set up. Applicable to only those areas
which are prohibited areas such as the Ordinance Factories, Mint, etc.,

Item 13

(B) - State the method of measurement of hourly/ daily maximum quantity of effluent
i.e., by flow meters, Venturimeters, V notch sump measurements, or approximately
estimated etc.,

Item 16(a)

If the effluent is treated, give separately the method of treatment and flow diagram of the
treatment process.

Item 16(b)

Here mention "Yes" if any other authority such as the local body, or Government
Department has already approved the discharge of effluent either with or without
treatment, at the time of establishment of the Factory/ Industry.

Item 19

Here give the quantity of effluent of different types such as domestic, industrial or mixed
Etc., Proposed to be or is let into the stream/river, land, sea etc., as may be applicable.

Item 22

Analysis to be furnished shall cover as many Parameters as or expected to be found, in


the effluent if some of the parameters are not excepted to be found, say not applicable. If
some other Parameters than those listed under the items are expected the same may be
mentioned at the end. The analysis shall be separately furnished for domestic/ industrial and
combined effluents.

Item 22(b)

Here toxicity means that which is established by bio-assay studies on fish, as per
procedure given in the Standard Methods.

Item 24

This item is meant to cover such highly polluting substances which do not ordinarily find
way in effluents, but are required to be handled in the premises, and which may, by
accident, join the effluent in large quantities.

*****

2051
QUADRUPLICATE
PRICE Rs. 50/FORM XIII
To be submitted in Triplicate
For Member Secretary
APPLICATION FOR CONSENT FOR DISCHARGE / CONTINUATION OF
DISCHARGE UNDER SECTION 25 OF THE ACT.
(See rule 32)
APPLICATION FOR CONSENT FOR DISCHARGE/CONTINUATION OF DISCHARE
From..
.
.

Date:..

To
THE MEMBER SECRETARY
Andhra Pradesh Pollution Control Board
Paryavarana Bhavan,A-3,Industrial Estate,
Sanathnagar, Hyderabad- 500018.
Sir,
I/We apply for CONSENT under Section 25 of the Water ( Prevention and Control of Pollution Act, 1974
( No. 6 of 1974) or bring into any new or altered outlet for the discharge of Sewage / trade effluent to begin to make
new discharge of sewage / trade effluents or continue to make discharge of Sewage / trade effluent from land /
premises owned by (1).
for a period upto (2) ..
(j) Sewage /sullage Via drains / outfall sewers / treatment works.
(k) Trade effluent Via, drains / outfall sewers/treatment works.
(l) Solid wastes into (3):
(i) Stream ..
River OR
(ii) Onland for irrigation, bearing Survey No.
Adjoining/ at a
distance of ..
stream/ river OR
(iii) Lake, pond adjoining / at a distance of stream/River OR
(iv) Directly on land for open percolation into sub-terranean strata of survey No..
ADJOINING / AT A DISTANCE OF
OR
(v) Tidal waters / estuarine waters know as OR
(vi) Sea along/ off the seashore shown as
2. The Annexure , Appendices other particulars and plans in triplicate are attached herewith.
3. I/We further declare that the information furnished in the Annexure , Appendices and plans is
correct to the best of my/out knowledge.
4. I/ We hereby submit that in case of change either of the point or the quality of discharge or its
Quality, a fresh application for CONSENT shall be made and until such CONSENT is granted, no
change shall be made.
5. I/We hereby agree to submit to the State Board an application fro renewal of Consent one month in advance of
date of expiry of the consented period for outlet/discharge, if to be continued thereafter.
6. I/We undertake to furnish any other information within one month of its being called by the state Board.
7. An amount of Rs paid towards consent fee for .. years.
Yours faithfully
Signature
Name of applicant
Address of Applicant
ACCOMPANNIMENTS:
Note :- Strike out entries not relevant.

ANNEXURE TO FORM XIII


EXISTING / NEW/ ALTERED
OUTLET/ DISCHARGE
Note : Any applicant knowingly giving incorrect information or suppressing any information pertaining thereto shall
be liable to punished under the Act.
While filling this Annexure, the applicant not concerned with any of the items shall state Not Concerned against
the relevant one:
1.

Full Name of Applicant with Address :

2.

Full Name of land premises/ institute/


factory/ industry/ local body with address:

3.

Give revenue / city survey number of land/


premises for which the application is made
stating District/ Mandal and Village.

4.

State : month and year in which the


land/ premises/ institute/ factory/
industry was
actually put into commission or is
proposed
to be put into commission or the month
and
year from which the local body is
functioning.

5.

State the Civil/ Military/Defence/


Industrial
Estate etc., under whose administrative
jurisdiction the applicant's land/ premises
is
situated.

6.

(a) State whether the land/premises/


industry/ factory has been declared as
prohibited area.

(Tel No.)

(b) If yes, state the name of the


Authority
and furnish a certified copy to the order
under which the area has been
declared as prohibited area.

(Tel. No.)
District ..
Mandal
Town.
Village.
City Survey No. Mouze No.
Area in Hectares .
Revenue Survey No.
Area in Hectares..
..

Collectorate
Corporation
Municipality
Village Panchayat
Cantonment
Defence Department
Port Trust
State Government
Prohibited Area
Yes / No

7.
8.

9.

Is the industry/ factory for which


application
is made closed on Sunday/ Holiday?
State Working season per year for the
industry / factory.

Yes/ No
Full Year
From
From
From
..

(a) No. of workers attending the factory


Unit/Section

Shift No.1 Hrs

Shift No.2 Hrs

(b) No.of workers residing in the premises


10.

11.

To
To
To
every year
Shift No.3 Hrs

General Shift Hrs

_________

For local Bodies only


(m)Present Population
(n) Population Covered under
regular sewerage facilities.
(o) Population covered by
conservancy latrines.
(p) Population having septic tank/
pit privy facilities.
(a) Give the list of raw materials, such as metals, alloys, chemicals, oil, fuels, etc., used per month in
Metric Tonnes :
Metal and Alloy
Chemicals

Name / Weight
Inorganic / Organic

Dyes I Pesticides

Name I Weight

Oils and Grease

Name I Weight

Fuel

(a) Wood

Name I Weight

(b) Coal

Name I Weight

(c) Oil

Name I Weight

(d) Gases

Name I Weight

(e) Others

Name I Weight

(b) Give the list of Names of products and by-products manufactures per month in (M.T)
SI. No.

Name of Products

( c ) Give the list of possible intermediate products:

Quantity in M.T. (Per


Month)

12.

13.

14.
15.

16.

16A
17.

18.

State daily quantity of water in litres


utilised.

A) State the hourly minimum and daily


maximum quantity of effluents arising
from land premises for which the
application is made.
(p) Domestic
(q) Industrial
(r) Agriculture
(s) Other use
(t) Total Quantity of effluent

USES
-----------------------------------------------------------(Domestic/Industrial/Agriculture/Other)
------------------------------------------------------(In Litres)
( Hourly Maximum / Daily Maximum)

(B) State how measurements of


RATE and QUANTITY are carried out.
State whether storm water drains are
kept separate from industrial/ domestic
effluents.
(a) Is domestic effluent allowed to get mixed
in industrial effluent ?

Yes / No
Yes / No

(b) (b) If yes, state ratio


(a) Describe if any treatment of industrial
or domestic effluent or one for the
combined effluent is made.
If yes, state the process of treatment in brief
(on a separate sheet)
(b) Is the quality of effluent emanating
either without or after treatment approved
by any authority?
(c) If approved, furnish the authority.
Is any effluent from any shop/ shops toxic? If
so volume of this effluent
Is there any provision for disposal of :
(j) Domestic effluent in public
underground Sewer.
(k) Industrial effluent in public
underground sewer.
(l) Give the name of the public authority
owning the sewer
Is there any provision for disposal of:
(p) Domestic effluent: on land for
irrigation
(q) Industrial effluent: on land for irrigation
(r) Domestic effluent in the
underground strata
(s) State the area of land used for (a)
above, in Hectares.
(t) State the area of land used for (b)
above, in hectares.

Domestic/Industrial
Yes / No

Yes / No
(Two certified copies to be send)
Yes / No
Already made

Proposed to be made

Yes/No

Yes/No

Yes/No

Yes/No

Already made

Proposed to be made

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

Yes/No

19.

Given quantitative disposal of effluent in litres provided for the places mentioned below:
Domesti
c

Industrial

Mixed

(i)Stream/ River ........................................................


(ii)On land for irrigation ..........................................
(iii)On land for percolation ......................................
(iv)Lake/Pond .........................................................
(v)Tidal Waters ..........................................................
(vi)Estuarine Waters ....
(vii)Open Sea ..............................................................
20.

Is there any provision for equalizing or holding lagoons for tanks to store the effluents during
unfavourable stream of tidal conditions?
Type of Effluent
i)Domestic effluent
ii)Industrial effluent
iii)Combined effluent

Already made

21.

Is sufficient land available / can be made available in


caste pumping of the effluent on land has to be
considered ?

22.

(a) Give details of composition of Domestic/ Industrial/ Combined


effluents in respect of the fol!owing:
Effluent before treatment
At
At
At
Max
Vain
Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)
OH
Colour - Units
Temperature C
Suspended solids :
(a)Total mg/I
(b)Fixed mg/I
(c)Volatile mg/I
(v) Dissolved solids :
(a)Total mg/I
(b)Fixed mg/I
(c)Volatile mg/I
(vi) Total volatile Matter mg/I
(vii) Ammonical Nitrogen (mg/I) N
(viii) Nitrates (mg/I) N
(i)
(ii)
(iii)
(iv)

Proposed to be made

Yes / No

Effluent after treatment


At
At
At
Max
Min Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

Effluent before treatment


At
At
At
Max
Vain
Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

Effluent after treatment


At
At
At
Max
Min Ave
Dis.
Dis.
Dis.
(1)
(2)
(3)

(ix) Dissolved Oxygen mg/I


(x)

BOD5 at 20C mg/I

(xi) C.O.D. mg/I


(xii) Oil & grease mg/l
(xiii) Chlorides (as CI) mg/I
(xiv) Phosphates (as P) mg/I
(xv) Phenolic compounds mg/l (as Phenol)
(xvi) Cyanides (as CN) mg/I
(xvii) Sulphides (as S) mg/I
(xviii) Sulphates (as SO4) mg/I
(xix) Insecticides mg/I
(xx) Total residual chlorine (as Cl2) mg/I
(xxi) Fluoride (as F) mg/I
(xxii) Boron (as B) mg/I
(xxiii) Arsenic (as As) mg/I
(xxiv) Barium (as Ba) mg/I
(xxv) Percent Sodium
(xxvi) Cadmium (as Cd) mg/l
(xxvii) Copper (as Cu) mg/I
(xxviii) Lead (as Pb) mg/I
(xxix-) Chromium
(a) as Cr (mg/I)
(b) Hexa-Valency (as Cr+6) mg/I
(xxx) Mercury (as Hg) mg/i
(xxxi) Nickel (as Ni) mg/I
(xxxii) Selenium (as Se) mg/I
(xxxiii) Silver((as Ag).mg/I
,(xxxiv) Zinc (as Zn) mg/1
(xxxv) Any other metals mg/I
(xxxvi) Calcium Chloroform Extracts
(xxxvii) Pesticides (mg/1)
(xxxviii) Coliform Organisms
MPN per 100 ml. (monthly average)
(xxxix) Bioassay for Toxic constituents. TL 50 (96) hours
Note:.(1)

Furnish a copy of the analysis report of representative samples carried out by a competent

(5)

laboratory
Methods of determination as approved by the Board will be followed for determination of
above mentioned parameters.

22.

23.

(e)

Yes / No

Is the effluent toxic?


(c)State if the industrial effluent is having
xiii. Unpleasant smell
xiv. Irritating and / or harmful effect
xv. Corrosive
xvi. Colour

Yes / No
Yes / No
Yes / No
Yes / No

(d) Is there any sudden change of temperature


exceeding 10C at any time ?
Are
facilities available with the applicant for carrying out the following tests of the waste water ?
(a)
xiii.
xiv.
xv.
xvi.

Existing
Yes/No
Yes/No
Yes/No
Yes/No

Physical
Chemical
Bacteriological
Toxicological

Proposed
Yes/No
Yes/No
Yes/No
Yes/No

(b) if yes, details of equipment


24.

Does the Land/ Premises etc., (for which application is made) have open
Highly Polluting Matter
Toxic

Organic

Inorganic

Microbiological

(a)Cooling Tanks
(b)Mixing Tanks
(c)Mixing ponds

Which contain

(d)Re-circulation wells

25.

State details of solid wastes


Dis.

Qty.

Method of collection

Method of disposal

Seasonal Waste
Spillage
Rejected materials
Signature
__________________________________
Name & address of the applicant on behalf
of________
Name and address of the firm
__________________________________________
_

ACCOMPANIMENTS
Flow Sheet of effluents

EXPLANATORY NOTES FOR FILLING IN FORM X111 AND THE ANNEXURE


The Notes are given only for those items for which explanation is considered desirable : other
items are self explanatory.
Form XIII
Here mentions the name of the owner of the land/ premises if other than the applicant industry of
factory if the land/ premises belongs-to-the factory / industry say SELF.
2. Here mention the date upto which the Consent is sought for.
3. Here mention the local name of the river/ stream tidal water/sea as may be applicable.
1

"Outlet"

ANNEXURE TO FORM XIII


Means the arrangement for discharge of the effluent for which the Consent is sought for

"Discharge"

Means the effluent going out of the outlet.

"Existing"

Means that which is in operation at the time of applying for Consent.

"New"

Means that which will be brought into operation in future.

"Altered"

Means that which has been modified due to charge in quality and/or quality or discharge.

Item 1

-Here give the name of the person who is authorized by the instruction/
Industry/Factory/Local body etc., to transact their legal business.

Item 2

-Here give the registered name of the Institution/ Factory/Industry etc., under which the
business is carried out

Item 5

Here state the concerned institution as Bureau of Public Enterprises, under whose
administrative control the Factory/ Industry etc., is set up.

Item 6

Here state the concerned institution as Bureau of Public Enterprises, under whose
administrative control the Factory/ Industry etc., is set up. Applicable to only those areas
which are prohibited areas such as the Ordinance Factories, Mint, etc.,

Item 13

(B) - State the method of measurement of hourly/ daily maximum quantity of effluent
i.e., by flow meters, Venturimeters, V notch sump measurements, or approximately
estimated etc.,

Item 16(a)

If the effluent is treated, give separately the method of treatment and flow diagram of the
treatment process.

Item 16(b)

Here mention "Yes" if any other authority such as the local body, or Government
Department has already approved the discharge of effluent either with or without
treatment, at the time of establishment of the Factory/ Industry.

Item 19

Here give the quantity of effluent of different types such as domestic, industrial or mixed
Etc., Proposed to be or is let into the stream/river, land, sea etc., as may be applicable.

Item 22

Analysis to be furnished shall cover as many Parameters as or expected to be found, in


the effluent if some of the parameters are not excepted to be found, say not applicable. If
some other Parameters than those listed under the items are expected the same may be
mentioned at the end. The analysis shall be separately furnished for domestic/ industrial and
combined effluents.

Item 22(b)

Here toxicity means that which is established by bio-assay studies on fish, as per
procedure given in the Standard Methods.

Item 24

This item is meant to cover such highly polluting substances which do not ordinarily find
way in effluents, but are required to be handled in the premises, and which may, by
accident, join the effluent in large quantities.

*****

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